Interview with a Pediatric Endocrinologist: Dr. Morey Haymond

Morey Haymond: A pediatric endocrinologist by training, I have been involved inmetabolic studies of kids, infants, and adults for 35 years. I work with children who have disorders ofcarbohydrate metabolism, including diabetes and hypoglycemia. Understanding the regulation of thoseprocesses has been a focus of my research, and I have looked at amino acid and fat metabolism as well.

Close to 70% of my patients have the autoimmune variety of diabetes, type 1, wherein their body rejects the insulin-making beta cells, leaving theminsulin insufficient. About 30% to 35% of our newly diagnosed kids have adult onset type 2 diabetes,usually associated with obesity, family history of obesity, and African-American or Hispanic-Americanethnicity.

Q: When you have diabetes, isn’t it important to follow a dietary regimendesigned to control your blood sugar?

Morey Haymond: If you are a type 2 diabetic, that is correct. We try to get people ona lower caloric diet so that they lose weight and increase their insulin sensitivity. People with type2 diabetes make insulin, sometimes a lot of insulin, but their bodies are resistant to it. If they loseweight, they become more insulin sensitive. We generally manage these patients with diet and oralhypoglycemic agents. For type 1 diabetes, we try to match the insulin that we give with the carbohydrate that they consume. As long as the kids arenot overweight, we can give them a wide variety of carbohydrates as long as we cover them with insulin,and we monitor and manage their blood sugar. We don’t try to control the Type 1 diabetics with diet per se; instead, wematch the carbohydrate consumed to the insulin administered.

This gives the kids a lot more freedom in their diet selections, allowing them to participate in partiesand eat high carbohydrate meals as long as they calculate the carbohydrates and give the amount ofinsulin necessary. Now, that’s assuming that they are monitoring their blood sugars regularly andthat they are in reasonable control to start with.

If they are not monitoring their blood sugars, then they are probably not going to be in good control.It is the high blood sugar itself that causes the long-term micro-vascular complications in type 1 diabetes. And, there is some evidence thatperhaps in the type 2 patients, it’s the high fat content that is causing the long-term damage. In either case you are pushing the oxidative metabolic pathways beyond their capacity, and you end upwith oxidative damage to tissues that occurs over time.

Problems with micro-vascular circulation in the capillaries, in both type 1 and type 2, lead to poor circulation in predominantly peripheral vesselslike those in the feet. Micro-vascular problems also cause peripheral nerve damage and the kidney damagethat can ultimately lead to kidney failure. In type 2 diabetes, you can get macro-vascular disease,which is that the large blood vessels clot occasionally. As a result, when you walk, you get pain inyour legs. But, we primarily focus on the small vessel damage that is the real killer in diabetes.

Q: What are some of the specific dietary measures to take in the case of type 2diabetes?

Morey Haymond: The big issue we focus on is weight. If you are overweight, you areconsuming more calories than you are burning. The body is very efficient in storing fat for lean timesthat never come in our societies today.

With our type 2 diabetic children, we reduce their caloric intake in any way we can that’sreasonably acceptable to them and to their families. It’s really a family and cultural problem. In many homes, the children are ingesting very high amounts of carbohydrate in the forms of soft drinksor juices, which are really just flavored water with sugar added to them in many cases. Getting thechild to convert from a regular Coke or Pepsi, to one that has no sugar will often reduce caloric intakeby 500 to 1500 calories a day.

We try to help the children reduce their number of high carbohydrate feedings. Note that there isnothing inherently wrong with sugar; it’s a nice metabolic fuel. It’s only a problem when itis consumed in excess of the calories that you need. We also try to get children to lower their fatintake, because fat calories are the densest. You can easily make small adjustments in diet by movingfrom high fat foods such as whole milk to skim milk, by eliminating butter, and by staying away fromfried foods. They taste wonderful, admittedly, which makes it very difficult to change behaviors. Butwe do whatever we can to help children first to reduce caloric intake, and second, to increase energyexpenditure by walking, joining exercise programs, and getting into sports.

Q: You mentioned fruit juices earlier, and noted that some of these are mostly waterand sugar, with just a little bit of fruit in it. Aren’t there also categories of fruit juicesthat are unsweetened and produced purely from fruit?

Morey Haymond: There are; they are usually more expensive. From a nutritionalstandpoint they have a distinct advantage over the other type of juice. But they do have high amounts oftheir own glucose, and fructose, and sucrose in some cases. The sugar that’s found in naturalfruit juices is the same sugar that may be added to fruit juices that are simply fruit flavored and thensupplemented with carbohydrates, and the body handles them the same way.

Q: Isn’t it true that the body takes sucrose or fructose and converts it intoglucose?

Morey Haymond: That’s partly correct and partly not correct. Sucrose is made upof fructose and glucose. If you consume fructose, very little of the fructose ever appears in thesystemic circulation. Most of the fructose is metabolized in the liver, and comes out as lactate; itdoesn’t come out as glucose on the first pass. Glucose generally passes through the liver andappears in the systemic circulation just as if you are eating pure glucose.

If you look at milk sugar, it is made up of galactose and glucose. Most of the galactose portion istaken up by the liver, and a lot of it can be converted to glucose. When you co-consume it withglucose, however, your blood sugar goes up; insulin goes up, and a lot of that carbohydrate that’smade from the galactose ends up in storage form, as glycogen in the liver.

Q: What about Exchange Lists? Are these still in use today?

Morey Haymond: We don’t use exchange lists, at least in our practice, for kidswith type 2 diabetes. We just try to get their caloric intake down and exercise up. We do use exchangelists sometimes with type 1 patients. Anexchange is roughly fifteen grams of carbohydrate. We are moving away from exchange lists and tocarbohydrate counting, but for some people calculating the carbohydrate content of food is a complexissue. Exchange lists are basically known amounts of food that all contain the same number of grams ofcarbohydrate, so that we are able to pattern what the patient can eat from day-to-day. There areexchanges for meats and for fats that we used to use a lot more than we currently do.

Q: There are also some foods that you can think of as free foods. Can you discussthose a bit?

Morey Haymond: There are some foods that are free of carbohydrates, and some that arecalorie free. There are also foods that are free of both. Examples of these include celery, carrots,pickles, diet drinks containing aspartame or another artificial sweetener, and water. Examples ofcarbohydrate-free foods that still have calories are cheeses and meats. However, those also have a fairamount of fat in them, and if weight is a concern, then they should be avoided.

Q: If you are pre-diabetic or have a family history of diabetes, are there classes offoods that help to reduce the chance of developing diabetes – for example, foods with polyunsaturatedfats and fiber?

Morey Haymond: My professional opinion is that, if you continue to gain weight and youare prone to type 2 diabetes, you are going to get type 2 diabetes. And, if you are in a family inwhich type 1 autoimmune diabetes occurs and youhave antibodies, there is probably very little that we can do from a dietary standpoint to alter thatprocess.

There are tests that show some benefits in mice and rats, but it is very difficult to expand this to thehuman environment, for which there is frequently no meaningful data in controlled trials. A lot ofthings are advocated as being preventive or preserving beta cell function, but they are by and largeunproven, with the exception of a very few. One of these is weight loss, and the second is using someof the insulin-sensitizing drug if you are already a type 2 diabetic. And, if you are a new onset type 1 diabetic, getting your blood sugars in verytight control may prolong what we call the honeymoon phase. But for type 1, ultimately there is very little that one can do.

Q: Assuming that you have your weight under control and exercise regularly, are thereany foods that are known to increase the risk of bringing on diabetes?

Morey Haymond: Not that I am aware of. There is a myth that children get type 1 diabetes because they ate too much sugar,but that’s totally a myth. Often parents feel very guilty when their child is diagnosed withdiabetes, thinking that they did something that caused this to happen. It’s in the genes. Wehave no control over it at the present time.

Q: With the exception, of course, of managing weight, right?

Morey Haymond: Absolutely. Children now develop type 1 diabetes two to three years younger than used to be the case. I think thereason is that they are higher in body fat now than they used to be, so they are more insulin resistant.A defect in insulin secretory ability will show up sooner rather than later in the obese child who isprone to type 1 diabetes. Althoughthat’s the primary explanation that a number of us have, there is no proof for it. But I think youcan make correlations and then come up with logical explanations with no proofs.

Q: Are there any other myths that you would like to take the opportunity to bust rightnow?

Morey Haymond: People get mega-vitamins, macronutrients, and supplements thatthey find in the stores, but there is only so much vitamin that you can use. I often caution familiesthat these are very expensive; people are spending $50-80 a month on supplements.

Q: Are you saying that there is no use for supplements, or that they just need to beused judiciously?

Morey Haymond: We focus first on getting people on normal, well-balanced diets. Supplements may help if you have a deficiency of some sort, but for most people it’s enough to buya once-a-day multivitamin and mineral supplement from a reputable company.

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